What are the treatment options for cluster headaches?

Cluster Headache Treatment

For acute cluster headache attacks, immediately administer 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes, or subcutaneous sumatriptan 6 mg if oxygen is unavailable or contraindicated. 1, 2

Acute Treatment Algorithm

First-Line Options (Choose Based on Availability and Patient Factors)

High-Flow Oxygen Therapy:

• Administer 100% oxygen at a minimum flow rate of 12 L/min via non-rebreather (reservoir) mask for 15 minutes at attack onset 1, 3
• 78% of patients achieve pain relief within 15 minutes compared to 20% with placebo 1, 4
• This is the safest option with no significant adverse events 4
• Critical pitfall: Flow rates below 12 L/min are insufficient—proper equipment and adequate flow rates are essential for efficacy 1
• Home oxygen should be prescribed for self-administration during attacks 3

Subcutaneous Sumatriptan:

• Administer 6 mg subcutaneously at attack onset 1, 2
• 49% of patients achieve pain relief within 10 minutes, and 74-75% within 15 minutes 1, 5
• For cluster headache specifically, 74-75% achieve relief at 15 minutes compared to 26-35% with placebo 5
• No additional benefit from 12 mg dosing over 6 mg 5

Alternative Acute Options

Intranasal Zolmitriptan:

• Administer 10 mg intranasally as an alternative to subcutaneous sumatriptan 1, 2
• Particularly useful when subcutaneous administration is not feasible 3

Noninvasive Vagus Nerve Stimulation:

• Consider for short-term treatment of episodic cluster headache when medical treatment is contraindicated or side effects are intolerable 1, 2, 6

Medications to AVOID

Never prescribe the following for cluster headache:

• Oral ergot alkaloids 1
• Opioids 1
• Barbiturates 1
• These have poor efficacy, potential toxicity, and risks of dependency 1

Preventive Treatment Algorithm

For Episodic Cluster Headache

First-Line Prophylaxis:

• Galcanezumab is the first-line prophylactic treatment with the strongest evidence for episodic cluster headache 1, 2
• Critical caveat: Galcanezumab is NOT effective for chronic cluster headache and should not be prescribed for this population 1, 2
• Expect 3-6 months for monoclonal antibodies to become fully effective 1

Alternative Prophylaxis:

• Verapamil (at least 240 mg daily, titrate based on efficacy and tolerability) is commonly used, though recent guidelines note insufficient evidence for a strong recommendation 1, 2
• Expect 2-3 months for oral preventive medications to become effective 1

For Chronic Cluster Headache

Preventive Options:

• Do NOT use galcanezumab (weak recommendation against) 2
• Verapamil may be considered, though evidence is insufficient 2
• Consider neuromodulation approaches for treatment-refractory cases 6

Bridge Therapy

Use bridge therapy while waiting for preventive medications to take effect:

• Oral corticosteroids (prednisolone) 7, 6
• Pharmacological block of the major occipital nerves 7

Interventional Procedures

Do NOT recommend:

• Implantable sphenopalatine ganglion stimulator—insufficient evidence and weak recommendation against 1, 2

Additional Considerations

Lifestyle Modifications:

• Advise patients to avoid nitrate-containing foods (processed meats, aged cheeses) as these may trigger attacks 1

Treatment Selection Factors:

• Oxygen therapy is unaffected by attack duration, patient age, gender, or concomitant prophylactic medications 5
• Subcutaneous sumatriptan efficacy is similarly consistent across patient populations 5